PEIN? Ankle Sprain Rehabilitation Farr Nguyen, Stephenson Lateral Ankle Sprain ‘Acute Phase Goat Protect from frther injury Methods + Rest + Tape (90 Fig 5-4), brace sping or walking boot (boot pimarly for pads Il). + Crutches or cane as needed (primarily for grades Ii) Goat Encourage ussve healing Methods + Rest + Protection (tape, brace, walking boot. ete) + Pulsed ultrasound ater 3 dy) Goat Limit pan, swelling spasm Methods + Rest + Iceleryotherapy + Compression (elastic wrap, compression stocknet Inearmictne compression dvi) + Elecrcalstmuliion + Ankle pumps with ankle elevated + Grade jone mobilizations (ter 3 days) (caution with anterior mobltzaions of che talus) (see Fig 5-10) + Manual herapy techniques to adress postional faut of talus andlor fibula (00 Fig 5-5) Gost Maintain function of noninjred tesues Methods + Pain free pase range of mation (PROM), acvesssisted range of motion (AAROM) active range af motion (AROM) 1 Anile puns + Heel cord stretches + ABCs or slphabes (canbe performed in the cold whirfpool bath) + Towel curs (se ig, 5-84). toe pick-ups (oe Fig §-88) + Parca weightbearng (PWB) or il weightbearing (FWVB) {Goal Malrain overall body conditioning Methods + Saaionay bike + Upper body ergometer + Open kinetic chan knee flexion and extension exerises, + Open kinetic chain hip lason exxension. abduction, adduction exercises Trunk exercises + Upper extremity exercises (prone supine. seated. non weightbearing (NWB), PB) ‘Subacute Phase Goal Prevent further injury Methods + Continue taping or bracing + Gradually progress into retataton and reconditioning aces Goat Promore tesue healing, Methods + Inredicethermotherapy (hot packs, warm whirlpool bathe) + Unrasound (progressing to contnuous cycle) + Massage (flushing techniques in early stages, cross ricton techniques in ater stages) Gost Panimice pun and ifareraton Methods + Cayotherapy (es bags cold whitpool Baths) + Gradual trodes thermodherary (hot packs warm vito! bath) + Conainus uernoound > Bectrelstrdtion + Grade to I oine mabitzaions + Massage (uthing techniques) Goal Restore range of ction and fexiiey Methods + Progress with pain-free PROM, AAROM, ROM. + Planarflesion, dorsiflexion version. inversion (as tolerated) (eee Fig. 5:6A-D) + Ankle pups + Heel cord stretches (ae Fig 5-7) + ABC! or alphabets (canbe performed in the cold “whilpoot bath) + Seated BAPS (see Fig. 511A) or ankle dic cices (progress 0 POVB [oe Fig 5-116 and FB [roe Fig 5-11C] ae elated) + Jone mobizations(progresing to grade II as needed) (Goo Fig 5128-0) + Soft isue techniques (erage, myofatci relase, te.) Goal Re-estableh neuromuscular control and restore ‘muscular strength and endurance Methods Towel cure + Marble piek-upsAnkle Sprain Rehabilitation (Continued) + omen strenghaning exercises + Progesting to toni srerghening mercons + Maral reac owe Fg 5+ 12A).cf weights (ne Fi S-128), ‘tase bans eee Fe 5-13C). ee = BNE pacers + Progressing f0 PWE the FW strengthening exercises (elise i SA on rae we Fi 18) Goat Re-esibth proprioception. agiy. and coordination Mechods + Jone repositioning (early sages) + Progress to PWB and FW actives as tolerated + Weigh shes (orward, backoward cealh) + Blox step-ups and sep-downs (ee Fig 515A and B) + Progress fom double-legged stance to tandem stance © ingle lased + Progress from raic tances so dynamic actives Geehig SI6AE Rg 5-17 And 6) + Progress fom eyes open to eyes closed + Progress to actives with perturbations + Progress fom a stable surface to an unstable surface + Walking walking backward, ont hinges, backward lunge + Sideboard (oe Fig §-188),Fiter machine, BAPS board, ‘wobble board, inlde sue ete + Graualyineroduce funcional actives in Inter weske Goat maintain vera boxy conetoning Meenoas + Upper body and trunk conditioning + stationary beng + CRE exercises equa. nges eg press. cal press) Fig 5-19. Rina) + Swimming + Unload rem) + Progress to FW acawtis (walking str climbing, Jain) ‘Maturation Phase: Goal Preven reiciory Methods + Continue aping or bracing Goat Restore ROM and exbiiy Methods + More aggressie stretching 1 Dyan stretching actives + Joint mobitzaons (grade IV a a 2 Fis Goat improve muscular strength endurance. and power + Continue exercises fom subacute sage emphasing Irorones, proprioceptws neuromezcur fst (PNF), ‘Sosed knee emnn (CRC) exercise + Pyometries + Functoal exercises (uping running changes of direction) Pati (p00! running, UNI unloader anergy ed) Goat Improve propriocepion agile and coordination * Emphasize advanced, dyramie execs + tances with perturbation (Le. plying etch) + Single leazed sances + Lungesequnts on an unetable surface (Fg 5-18A) + Gearees with eer closed + Jumpin rope + Foursquare hops/sde to side hops (Fg 5-53) + Shue rane + SEMO si ‘Shadow boxing” Goat Restore faneionaleporcespecii ils Methoos! + Foursquare hops + Shue rane + SEMO | + "Shadow boxing + Forward running, backward runing eral shes, caioca, femeeighe rinsing citing hopping siping «Return to sporuictivity des Goat Maintain overall bad conditioning Methoge| Upper body and wrunk condoning + Sationary Brg + CKC exereises (squats. hinges eg pres, calf press) + Walking opsing. running sar cling swimmingAnkle Sprain Rehabilitation (Continued) PEE After Modified Brostrém Ankle Ligament Reconstruction Modified Hamilton Protocol Days 0-4 Pace ankle in neutral dorsiflexion in removable waking boot and atcharge patient as weghtbearing 35 tolerated (WBAT) in boot with rutches. Maximally elevate and cryotherapy. ‘Wean crutches at 7 to 10 days co walking boot only WAT. Days 4-7 Progrets WBAT in removable walking boot and wenn crtches at day 7 0 10. Week Remove walking bot a 4 to 6 weeks. ‘Apply ar spline fr protection, to be worn for 6 to 8 weeks after surgery. Begin gente range of motion (ROM) exercises ofthe ankle Begin icometrc peroneal strengthening exercises. ‘Avoid addon and inversion of ae und 6 weeks postopera, Begin stonary cycling and lige swimming Week 6 Begin propriocepson/balancng actives. After Modified Brostrém Ankle Ligament Reconstruction (Continued) Unilaerl balancing for med intervals Uniacerl balancing with visual ces. Balancing on one leg and catching 2 plobal. Sd board increasing astance, Ftcer atv caching ball. ‘Sidecto-side bateal hopping (progress vo unter. Frone-o-back bilateral hopping (progres 0 unlatera. Diagonal patterns, hopping, Mineeramp jorge. Shuttle lg press and rebounding, bilateral and unilateral Positive deceleration ankle eveter,Kin-Com. ‘Complete rehabilitation ofthe peroneal is essential Dancers should perform peroneal exercises in fll ‘Panerflexion the position of funcvon in chese athletes. Early in reabiltavon,deweighted pool exerlses may be benef Dancers should perform plantarflexion/everson exerises witha weighted bel (2-20 pounds). Weeks 8-12 Patient can return to dancing or sport if peroneal strengths normal and symmetric with uninvolved limb,PEO ‘Conservative Treatment for Syndesmosis Injury (Lin et al. 2006) + Pain and sweling contrl:ret.ce, compression elevation {ICE}: elocriealsumulation, oe cure ankle pumps Sryotherapy + Temporary stabilization (short leg cast spline brace. he! in + Nonweightbearing with crutches Criteria for Progression + Fain and sweling subside + areal weighebearing posible with asstve device + Ambulation,parsl weightbearng without pain * Low-level balance taining: blateral standing ach: standing ‘on balance pad or several layers of towels + Lowerlevel strengthening with Theraband ‘Criteria for Progression + Full ambulcion with weightbearing without pain, possibly ‘vith ankle brace or hel Phase I = Unilateral balance erining + Progress from doubla-heel raises 9 snge-he «Treadmill walling or overground walking. + Progression to fst walling Criteria for Progression Phase 1V + Fase pintree walking without pain left + Jogsto-un progression + Shute run and eating maneuvers + Spore specific eraining PEON ‘Treatment Algorithm for Plantar Fasciitis (Neufeld and Cerrato 2008) ‘A. tnitial Treatment + Over-the-counter (GTC) nonsteroidal antifammatories (NSAIDS) (weak evidence wo support this) + Hee pads or OTC orthosis + Night splincing {No Improvement Afcer 4-6 Weeks + Immobilization in 3 castor eam walker + Radiographic evaluation co rule ou stress fracture or other pathology + Physical therapy wich emphasis on plancar fascia stretching and chile stretching * Cuntom orthouis + Presenption NSAIDs (weak evidence to support hie) + Corticosteroid injection a planar fasca origin C.Persiseent Symptoms Beyond A and B +i zome improvement has been made, reatment plan i continued + Mino improvement. MRI to confirm diagnosis rule out stress fescture ote + Consideration of aernativecreatmancs such 38 ‘Sctracorporeal shock wave therapy (ESV) + Surgery (partial release of <40% of faci) is considered iy Wl other ete a and te psec Ps pan n (Forme from information in Nev SK Carrio A Prarfsis Erkntion and retment/Am Acad Cth Sarg 1638-246, 2008) ‘After Rupture of che Plantar Fascia Phase 1: Days 0-14 + Immediate nonveiahebearng with crutches 1 Ughe compression wrap changed reverl Gmes a day for 2-3 oon + Nea therapy with ou mange of swollanacchymote feraral Ses so {leaping with pilows ander re foo = Higrwetptaring tn ergs css on hy 3, worn or = NSAIDs (not coneranceased) for 2-3 eck 1 Ul oF I/Bne fle pd placed from heel zo heads of ‘petatarais ana lightly strapped wes bancage (Saban, Une EAC Rimtneo wanes coon sock or Coban heap rather a veightbesringn bose ony fain he pcg ‘ctr or proprenion of weighebearing + Enorcnas are bogun a pin allows + Deepawater running wich Aqusjoggercom flotation bee + Aceive alla strengthening sxarces are progrenred Becerra os made peracid Erpipaz agonal none son) + Ute ofa custom orshovc layered with an overying fe ‘sine ac a Renee) we ep er Sand ‘mare than 40%. For this reas Injections thould Teh evenbs used isPEE nares Home Rehabilitation Program for Plantar Fasciitis ‘Component. Procedure ‘Duration and Frequency wretch | In sanding postion, with involved foot Perform tis exercive a furchese away from the wal, lean forward | home 3 times dail for 2 ‘while keeping your heel on the floor and | repettions, holding each for knee bent Lean forward unt you fee a 30 seconds stretch nthe elf andor Achilles region, Stretch 2 In sanding positon, with involved foot Perform this exercise a¢ furches away from the wal lean forward | home 3 times dal for 2 ‘while keeping your heel on the floor repetitions, holding each for and the back koe straight Lean forward | 30 seconds, {nel you fee a stretch inthe ea andlor ‘Achilles region. ‘Ankle everson sel- | Stblze your leg with your arm as shown. | Perform in an on-off fashion ‘mobilization ‘Your stabilizing and should wrap around | 30 times, repeat 3 times the very end of your lg, just above your rile. Use your other hand to grasp the back part of your foot and push toward the flor: Seltatetching and | Cross the affected leg over the nonaffeced | Perform for 3 to § minutes, mobilzation of | — eg. While placing your fingers over the planar fsclaand | base of your toes, pul the toes back flexor hallcis toward your shin until a strecch is ein longus your plantar fascia, With your other hand, ‘obilze the plantar fascia and flexor hallucs longus from your heel coward your toes. Stare gel a rst then work ‘Seeper a tolerated From Cleland A Abbr JH. Kid, Stockwel 5, Cheney 8, Gerard DF Fyan TW. Manual psi therapy and exces versus eecrophysial agents nd orca the maragement of pear heal picArubicntar andomzedchtsl Pak] Ordos Spores Pys Ther 36) S85, 200%,PEIN ‘Treatment of Achilles Paratenonitis Phase 1:0-6 Weeks + Rest andlor activity modifiation i required to reduce symptoms to level that can achieve pain ree activity. + Hfpain is severe.a walking boot or cast worn for 3-8 ‘weeks eo allow pain free activites of daly living + Crutch.tsrted ambulation it added when there is persistent pala wie boot or ease + Mose paiens have chanie pain that requires anita period of complete rest une symptoms subside followed by ‘ehablitavon and gradual reurh to acces, “NSAIDs and ice massage decrease pain ané inflammation, particulary in che acute phase + A sererhing program i essen Geadle cl Achilles and hamsering stretching s done thre to four times a day. + Acute pain usually resolves in che frst 2 weeks. + Footwear i changed or modified if overpronation or poor hhindfoot suppor is present. + Athleseseity * Gradual return to acy. + Adequate warmup and cooldown periods + Presexercse and postexercise stretching of gastrocnemius and soleus complex + Decrease duration and intensity + Decrease training on hard surfaces, + Avoid hill an incine wining. + Replace inadequate of worn out foorwear + Progress to genie strenghenig using lowsrmpact exercises Phase 2:6-12 Weeks + Indicated for fled phase | or recurrent symptoms afer previous resolution + Repeat or continue phase | immobilization and stretching += Adé modes * Concrase baths + Ultrasound + Footwear + Sal eel fe for severe pan + Arch support orthotic if overpronation. + Persistent heel-crd tightness is teated with stretching exercises and use of 5dogroe dorsiflexion night ankle foot brthoss (AFO) worn for 3 months whle seeping, + Staged erostraining program for mose athletes, expecially + Aqua jogging and swieming stationary cycling exercie fon stair climbing and cross-country shing machines. Avoid Fepeutve impact loading (eg. runing). Phase 3:3 Months and Beyond + Brisement (ony for paratenoniis) * Dilute local anesthetic and sterle saline injected into the paratonon sheath to break up adhesion between the inflamed paratenon and the Achilles tendon (preferable to steroid injection). Can be done with ultrasound to confirm ‘correct placement + Corticosteroid injections + Generally avoided + Raral indicated only for recalcitrant cases to inhibi Inflammation and prevent sear formation. + Rak of adverse affect fnjcted ino tendon or Ht ceverused is generally worse than any known benef PoE General Guidelines for Achilles Tendonitis, Paratenonitis, and Tendinosis, in High-Impact Athletes ~ Esableh correct dagnos + Correct underlying training and biomechanical Stop raid increase in meses + Scop il unin + Correct improper intensity of training duration schedule tard surface. and poor shoe wear + Decrease mange sigiiartly andor inate crossing (ook biel) depending on Severity of Symptoms at ‘wrnging of he tendon (Fg 542) with acum orehode ‘ht ural incorporates a medal rea foot pore + Stop interval raining + Soften a hard feel counear or ute hos courcer hee Cushions to minimize posterior "rubbing symptoms + Begin a dynamic runners stretching program before and after + Onl antunflayratones (verche-counter or CO%2 inhibitors) + Avoid cortirone injection; ths wll caure weakening Orrupture of the tendon. + Cryotherapy (ce massage) after exercise for at Intammacary face ~ Corres tgslength dacrepancy i noced Firs ry I 4anch heaton aunhapings dcrpang Fn nlorchotiecorrecion of legen dropaney) may, rors symptoms +H symptoms pers afer 4-6 weeks of conservative ‘metre, inmobizaion in removable com Boot Or Est tay be required for 3-6 week, + Slow pails progression co prenury actives + Deop-vater “running” wich Aquajggercom foration bel + Bicyeing + Ligh ain Ezcenee strengthening of Aciles tendon should condition the tendon and mote tls suscepeble © overuse june howerer these exreses are not used un he panes aymgromase land pain re for 1-3 weelaiofen Weed the of-taton "Heel rises in poo! + Planarflesion against progressively harder Therabands. + Multile ses of very phe (20-pound) total gym or slider board exarcnes (Fg 554)PEE eas Protocol for Nonoperative Management of an Achilles Rupture Inial evalatonirequirement Yor indusion Inial management 2ewesk evaluation UUreasound or MRI exam showing 75% tendon apposition with foot in 20 degrees of plantarflexon. Case with fot in fl equinus with dorsiflexion blocle NWB. Transition o removable cast boot with foot in 20 degrees of plntarflxion WBAT with two Im ‘wedges in ast boot: boot worn 24 hours a day. 4-wosk evaluation! Cia examination: able to palpate continuity of tendon, Fequirmene Repeat ultrasound or FRI to verify hat tendon ends are apposed with evidence of no sping. f tendon edges not apposed, consider operative treatment Boot removed § minutes per hour when awaka co perform exercise of active dorsiflexion to neutral ‘wth passive planarflexon, G-week evaaion Cini examinadon to document tendon continuity Removal of I-em wedge. Continue active dorsflexion to neutral with passive plantarflexion. Inia physical therapy program co begin proprioception and NWB muscle strengthening out of the boot. Cina! examinaion to ensure tendon continuity Urtrasound or MRI to document continued tendon apposition. flack of tendon healing oF ‘nin, consider operative intervention I tandan i continuity transition of boot to daytime ‘wear ony without wedge Continue formal physi therapy program, Disconeinue use of boot and use a I-cm hesl wedge in shoe for 3 more months. May begin 19 ‘de stationary bike and progress phyial program with WBAT in shoe with lft. No spring or running ntl el wedge discontinued week evaluation lsweek evalstion MRL magne resonance imaging: NINE, nonweghbering WBAT.weghtearing 2 tlerated From Tan Sabb Kan AR Nan-surgel managemart Achilles rupres Fa Ale Cn 4675-484, 208, PEE Rehabilitation After Repair of Acute Achilles Tendon Rupture Immediately Postoperative Le placed in wall-padded posterior spline with scrrup with ankle in relaxed equinus postion. [Nonweightbearing briefly chen initiate weight bearing with ‘aking boot and smal et heel ie (apa), 2-6 Weeks Postoperative ‘symptoms to manitor to ensure they are not making adjusements too rapidly ‘Al patients taught acuve ankle gentle dorsfexion range of ‘motion exercises and to perform ewice daly ae tolerated 6 Weeks Postoperative Pasen instructed on weaning hineel from the ankle foot orthosis. Confirm Achilles repair intact with examination and ultrasound, Confirm stable wound/oft sue status, Use a fixe-angle hinged ankle foot orthosis (Motion Control ‘Walker, Donjoy Ortho, Vita, CA). Set brace ae 20 degrees of plntarflexon \Weightbearing as tolerated in boot with weaning of crutch sipport Patients instructed on how to slowly bring the boot fixed ‘angle from 20 degrees of plantarflexion to O degrees of Plntarflexion over 2 to 3 weaks. Patents insructed 19 make boot adjustments over 2 to 4.cay periods and what Progression of dorsiflexion plantarflexion, and range of ‘motion exercises with resistance tubing. Seationary cycling added Progressive hee raise with both lower extremities. 3 Months Postoperative Uniazeral heel raises added 2¢3 months 6-12 Months Postoperative IW patene pastes functional ests, resume recreations activites, Hel raise endurance should be 80 percent of unaffected mb Modified rom Suck AA, Bostk G.Benupre LA, Durand OC. Joma NM: The lence of ary weightbering compared wth nor~ ‘weatbearhy star mrp rapa of he Aces tendon ane ont urge 91876-1883, 2068PECs ‘Treatment of Turf Toe Phase I:Acute Phase—Days 0-5 + Rest ice bath, contrast bath, whipol bath and lrasound {or pin infammation.and joie sos. + Jone mobizaton Fg 5-5) fllowed by gene, passive. and Active range of motion (ROM), + Isometries around the metatarsophalangel jin spain allows + Crosstraining activites, such a5 water accvties and eeling for aerobic nes, + Protective taping and shoe modifications for continued ‘welghtbearing activites, Phase 2: Subacute Phase—Weeks 1-6 + Modalities to decrease inflammation and joint sess. + Emphasis on increasing flexiblcy and ROM, with bh passive and active methods and joint mobilization. + Progressive strengthening “Towel serunches “Toe pick-up activites. “+ Manual essvehallax MTP dorsiflexion and plntarfexon. + Seated toe and ankle dorsiflexion with progression to sanding, + Seated islated toe dorsiflexion with progresion to sanding. + Seated supnation-pronation with progression to standing. + Balance actives, with progression of dificult to include biomechanical anil platform system (BAPS) (F558) + Crossraining activities (sideboard, water running. cycling) tormainain aerobic Fines Phase 3: Return-to-Sport Phase—Week 7 + Continued use of protective insets oF taping. + Continued ROM and strength exerci. + Running, o progress within its of pain-free schedule + Monitored plyometric and cutting program, with progression of ciety. Care should be taken to avoid relnjry during these actives.